“Smart” pill boxes which send reminders to patients do not improve medication adherence as anticipated—implying “forgetfulness” may not play a role as significant as we once believed.

Non-adherence to medication is a challenging issue. The simple act of not taking the pill as prescribed by the doctors negates the financial and intellectual efforts of discovering and developing the medicine in its entirety. Studies have shown adherence to medication declines over time, apart from its inverse relationship with the complexity of the treatment regimen. Elderly patients and those with dexterity problems are particularly prone to missing their pills.

Enter the "smart" pill boxes, which were specifically designed to improve medication adherence. These devices are connected to the internet and are capable to track—in real time—whether the patients have been taking their medication. When a dose is missed, the sophisticated software embedded in these "smart" pill boxes will automatically analyse the scenario. It then provides a customised intervention ranging from automated phone calls or text messages to personalised support. As a matter of fact, the CEO of one such company has described the device as the “iPhone of pill bottles”.

Fame or shame?

Despite the anticipation and excitement over these devices, smart pill boxes were not capable to live up to their expectation, as shown by the HeartStrong randomised controlled trial. The trial investigators followed more than 1,500 patients who were hospitalised due to an episode of acute myocardial infarction, and were discharged with at least two of four study medications (statin, aspirin, beta-blocker or any antiplatelets).

Patients were randomly assigned into one of the two study arms: (1) the interventional arm with electronic pill bottles or (2) the control arm with usual post-discharge care. The primary outcome of the study was determined as the time to first vascular rehospitalisation or death.

"The expectation was that we would see a large increase in medication adherence—and that would then translate into a significant reduction in hospital readmissions and lower health care costs", stated lead author of the study, Dr Kelvin Volpp, who is also a health economist at the University of Pennsylvania's Center for Health Incentives.

By the end of the 12-month interventional study, the study team discovered there was no significant difference between the study arms in terms of the study outcome. In other words, either the patient was given an electronic “smart” pill box or not had made no difference to lengthen the time to rehospitalisation.

The HeartStrong Randomised Clinical Trial looked into the effect and correlation of electronic reminders, aside other factors, with rehospitalisation. Source: The Digital Apothecary/JAMA Internal Medicine

What went wrong?

The negative results of the study prompted us to ask “what went wrong?”

The investigation showcased a powerful example that medication adherence is a highly-complicated issue. Despite the state-of-the-art engagement strategies developed from behavioural economics were employed in the study—the problem of non-adherence was far from being adequately addressed.

One possibility is that “forgetfulness” may not be the main culprit. In fact, another study published in JAMA Internal Medicine which looked at the effectiveness of low-cost reminder devices to improve medication adherence found an equally disappointing result. There are many more layers of complex psychological and behavioural factors that contribute to non-adherence than simply attributing the problem to forgetfulness.

Another reason is where patients are intentionally refusing to take their medications, especially chronic medicines with severe side effects such as impotence. In certain cases, where the therapy requires life-long adherence to treatment regimens—such as HIV patients—treatment fatigue may be another confounder to non-adherence.

Merging technological advances with social interventions

Notwithstanding the study results, smart pill boxes may still have a bright future in promoting better medication adherence. The key is to merge technological advances with concurrent social interventions to address the underlying human factors. In the end, no one likes to swallow bitter pills if given the freedom to choose. MIMS